Submit a Photo - My New Beginning

Share your story.

Success stories are what keep the My New Beginning team passionate about caring for patients. It’s all about helping each and every person find the healthy, active life they’ve always wanted to have.

Share your success with us! Upload a photo below of the progress you’ve made and the steps you’ve taken towards your new beginning.

Home > Submit a Photo

Authorization for use of my health information for marketing/broadcast/publication.

The My New Beginning program is a service of White Rock Medical Center.

Submit a Photo

1
Choose File... * Required
Accepted file types: jpg, jpeg, png, gif.
Maximum size of 6MB. JPG, GIF, or PNG.
Starting Weight * Required
Weight in Photo * Required
2
First Name * Required
Date of Birth - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
Address
Middle Name
Phone Number
City, State
Last Name * Required
Email Address * Required
Zip Code
3
Link to Video (OPTIONAL)
Tell Us Your Story (OPTIONAL)
By Clicking “Agree” I acknowledge that
I have read and understand the terms of this authorization and I have had an opportunity to ask questions about White Rock Medical Center's use or disclosure of my health information for marketing and possible use in broadcast or publication. I hereby knowingly and voluntarily authorize White Rock Medical Center to use or disclose my health information for the purposes stated herein.
Authorization Agreement * Required
- I Agree